ICD-11 Personality Disorder in Adolescents: Potentials and Pitfalls

A special issue of Children (ISSN 2227-9067). This special issue belongs to the section "Child and Adolescent Psychiatry".

Deadline for manuscript submissions: closed (25 April 2023) | Viewed by 9763

Special Issue Editors

Psychiatric Research Unit, Psychiatry Region Zealand, 4200 Slagelse, Denmark
Interests: personality disorders; psychotherapy research; mentalization-based theory; psychopathy; social learning theory; evolutionary psychology
Department of Psychology, Aalborg University, 9000 Aalborg, Denmark
Interests: personality disorder; dimensional approaches to personality disorder; personality; narrative identity; life story; mentalization; psychotherapy

Special Issue Information

Dear Colleagues,

In the ICD-11 diagnostical classification system, a dimensional approach to personality disorder (PD) is introduced. Here, impairments in both self and interpersonal functioning along a dimensional line from no disorder to severe PD is at the very heart of the definition of the disorder. With this Special Issue, we aim to set the scene for scholars to discuss strengths, opportunities and potential pitfalls related to conceptualizing, diagnosing and treating adolescents with PD within the ICD-11dimensional approach.

We invite both conceptual and empirical papers on the topic of, but not limited to:

1) Why, how, and when to integrate a more dimensional approach to classifying PD in adolescence. How do we distinguish personality disorder from typical developmental challenges?

2) Integrating a dimensional approach to the classification of PD in adolescence mental health service will inevitably request new and more fine-grained clinical skills. Do clinicians have this knowledge? How do we prepare clinicians for these new demands? 

3) Is there a risk that we base our judgement about personality pathology in adolescence on more general functional measures instead of core dysfunctions in self and interpersonal domains? Hence, are we, due to a more “loosely” defined dimensional approach, running the risk of confusing externalizing an internalizing pathology for personality pathology?

4) May the implementation of a dimensional approach to PD led to either an out-phasing of PD treatment or, on the contrary, over-diagnosing of PD in adolescents?

5) Do we know enough yet about the normal “self” and “interpersonal” mode of functioning in adolescents to use these core features as central features in the classification of PD?

6) What aspects of self and interpersonal functioning are particularly central in adolescents with PD within the ICD-11, and furthermore, what aspects of self–other understanding need further examination for adolescents specifically?

7) What and how do we improve and select assessment to diagnose PD within adolescents from a more dimensional perspective?

8) Does a more dimensional conceptualization of PD in adolescents effect the way we design and organize our treatment of PD?

Dr. Sune Bo
Dr. Majse Lind
Guest Editors

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Keywords

  • personality disorder
  • ICD-11
  • adolescents
  • dimensionality
  • personality pathology

Published Papers (7 papers)

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Editorial

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2 pages, 158 KiB  
Editorial
Personality Disorder and Adolescents—Still Living on a Shoestring?
by Sune Bo and Majse Lind
Children 2023, 10(10), 1611; https://doi.org/10.3390/children10101611 - 27 Sep 2023
Cited by 1 | Viewed by 619
Abstract
Personality disorder (PD) has been and continues to be a controversial mental disorder to discuss with young people under the age of 18 [...] Full article
(This article belongs to the Special Issue ICD-11 Personality Disorder in Adolescents: Potentials and Pitfalls)

Research

Jump to: Editorial

21 pages, 1077 KiB  
Article
Impaired Personality Functioning in Children and Adolescents Assessed with the LoPF-Q 6-18 PR in Parent-Report and Convergence with Maladaptive Personality Traits and Personality Structure in School and Clinic Samples
by Gresa Mazreku, Marc Birkhölzer, Sefa Cosgun, André Kerber, Klaus Schmeck and Kirstin Goth
Children 2023, 10(7), 1186; https://doi.org/10.3390/children10071186 - 08 Jul 2023
Cited by 2 | Viewed by 3485
Abstract
To investigate if the Personality Disorder (PD) severity concept (Criterion A) of the ICD-11 and DSM-5 AMPD is applicable to children and adolescents, following the ICD-11 lifespan perspective of mental disorders, age-specific and informant-adapted assessment tools are needed. The LoPF-Q 6-18 PR (Levels [...] Read more.
To investigate if the Personality Disorder (PD) severity concept (Criterion A) of the ICD-11 and DSM-5 AMPD is applicable to children and adolescents, following the ICD-11 lifespan perspective of mental disorders, age-specific and informant-adapted assessment tools are needed. The LoPF-Q 6-18 PR (Levels of Personality Functioning Questionnaire Parent Rating) was developed to assess Impaired Personality Functioning (IPF) in children aged 6–18 in parent-reported form. It is based on the established self-report questionnaire LoPF-Q 12-18. Psychometric properties were investigated in a German-speaking clinical and school sample containing 599 subjects. The final 36-item version of LoPF-Q 6-18 PR showed good scale reliabilities with 0.96 for the total scale IPF and 0.90-0.87 for the domain scales Identity, Self-direction, Empathy, and Intimacy/Attachment and an acceptable model fit in a hierarchical CFA with CFI = 0.936, RMSEA = 0.078, and SRMR = 0.068. The total score discriminated significantly and with large effect sizes between the school population and (a) adolescent PD patients (d = 2.7 standard deviations) and (b) the younger patients (6–11-year-olds) with internalizing and externalizing disorders (d = 2.2 standard deviations). Informant agreement between parent and self-report was good at 0.47. Good construct validity can be assumed given sound covariation with related measures of psychopathology (CBCL 4-18, STiP-5.1, OPD-CA2-SQ PR) and maladaptive traits (PID5BF+ M CA IRF) in line with theory and matching the result patterns obtained in older samples in self-report. The results suggest that parent-reported assessments of IPF and maladaptive traits are equivalent to self-reported measures for Criterion A and B. Assessing IPF as early as age six might be a valuable step to foster early detection of PD, or maladaptive personality development, respectively individuals at risk. Full article
(This article belongs to the Special Issue ICD-11 Personality Disorder in Adolescents: Potentials and Pitfalls)
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12 pages, 278 KiB  
Article
Operationalized Psychodynamic Diagnostic of Adolescents in Light of the New ICD-11 Model of Personality Functioning: Personality Structure, Psychodynamic Conflicts, and Mental Health Problems
by Aslı Akın, Kirstin Goth, Inge Seiffge-Krenke, Alexander Obbarius, Sibylle M. Winter and Lea Sarrar
Children 2023, 10(7), 1095; https://doi.org/10.3390/children10071095 - 22 Jun 2023
Viewed by 1130
Abstract
The International Classification of Diseases and Related Health Problems, 11th Revision introduced a fully dimensional approach to personality disorders which conceptionally converges with the long-standing psychodynamic understanding of psychopathology through underlying intra- and interpersonal impairments. In this study, the diagnostic contributions of the [...] Read more.
The International Classification of Diseases and Related Health Problems, 11th Revision introduced a fully dimensional approach to personality disorders which conceptionally converges with the long-standing psychodynamic understanding of psychopathology through underlying intra- and interpersonal impairments. In this study, the diagnostic contributions of the two psychodynamic concepts of personality structure and psychodynamic conflicts were investigated through the comparison of self-report data of 189 adolescents with mental health problems and 321 mentally healthy controls. The study results reveal that adolescents with mental health problems show significantly higher impairments in all four domains of personality structure and significantly higher levels of several psychodynamic conflicts. Further, adolescents with different mental health problems significantly differ regarding the impairments in the personality structure domains and several levels of psychodynamic conflicts. While higher structural impairments are shown in adolescents with eating and anxiety disorders, higher levels of the passive self-worth conflict persist in adolescents with depressive disorders, and higher levels of the passive identity conflict are affecting adolescents with eating disorders. The findings suggest that a standardized diagnostic assessment of personality structure and psychodynamic conflicts in adolescent patients could contribute to a deeper understanding of mental health problems and appropriate treatment planning through the detection of underlying intra- and interpersonal impairments. Full article
(This article belongs to the Special Issue ICD-11 Personality Disorder in Adolescents: Potentials and Pitfalls)
18 pages, 332 KiB  
Article
Differential Diagnosis of ICD-11 Personality Disorder and Autism Spectrum Disorder in Adolescents
by Bo Bach and Martin Vestergaard
Children 2023, 10(6), 992; https://doi.org/10.3390/children10060992 - 01 Jun 2023
Cited by 6 | Viewed by 3875
Abstract
The International Classification of Diseases 11th Revision (ICD-11) introduces fundamentally new diagnostic descriptions for personality disorder and autism spectrum disorder. Instead of the traditional categorical taxonomies, both personality disorder and autism spectrum disorder are described as being on a continuum. Accumulating research has [...] Read more.
The International Classification of Diseases 11th Revision (ICD-11) introduces fundamentally new diagnostic descriptions for personality disorder and autism spectrum disorder. Instead of the traditional categorical taxonomies, both personality disorder and autism spectrum disorder are described as being on a continuum. Accumulating research has pointed out that, in some cases, adolescents with autism spectrum disorder are at risk of being confused with having a personality disorder, which particularly applies to female adolescents. Case reports describe how adult autistic women struggled with social and identity roles as children and adolescents, using compensatory strategies such as social imitation and other types of camouflaging. Furthermore, some adolescents with autism display emotion dysregulation and self-injury. The ICD-11 recognizes that features of autism spectrum disorder may resemble features of personality disorder, but the two diagnoses have not yet been formally compared to one another. The present article therefore sought to outline and discuss the overlap and boundaries between the ICD-11 definitions of personality disorder and autism spectrum disorder and propose guiding principles that may assist practitioners in differential diagnosis with female adolescents. We specifically highlight how aspects of the self and interpersonal functioning along with emotional, cognitive, and behavioral manifestations may overlap across the two diagnoses. Restricted, repetitive, and inflexible patterns of behavior, interests, and activities are core features of autism spectrum disorder, which may be masked or less pronounced in female adolescents. Collecting a developmental history of the early presence or absence of autistic features is vital for a conclusive diagnosis, including features that are typically camouflaged in females. A number of future directions for research and clinical practice are proposed. Full article
(This article belongs to the Special Issue ICD-11 Personality Disorder in Adolescents: Potentials and Pitfalls)
12 pages, 804 KiB  
Article
Narrative Identity within Mentalization-Based Group Therapy for Adolescents: A Feasibility Study
by Majse Lind, Lennart Kiel, Sune Bo Hansen, Mie Sedoc Jørgensen and Erik Simonsen
Children 2023, 10(5), 854; https://doi.org/10.3390/children10050854 - 10 May 2023
Viewed by 1440
Abstract
Borderline personality disorder (BPD) is characterized by severe disturbances related to understanding oneself and other people and can be reliably detected and treated in adolescence. In this feasibility study, we aimed to focus on the features of, and changes in, narrative identity throughout [...] Read more.
Borderline personality disorder (BPD) is characterized by severe disturbances related to understanding oneself and other people and can be reliably detected and treated in adolescence. In this feasibility study, we aimed to focus on the features of, and changes in, narrative identity throughout the course of Mentalization-Based Treatment in Groups (MBT-G) for adolescents with BPD. Six female patients (M = 15.2, SD = 0.75) joined between 16 and 31 (M = 23.83) MBT g sessions. The narrated events within each session across sessions were coded for themes of agency and communion and the narrated reactions were coded for personality functioning. The patients and their parents also completed several self-report measures before and after therapy. Themes of diminished agency and communion were identified, with communion as the dominating theme. When comparing the patients’ first five sessions with their last five sessions, there was an increase in themes related to agency and decreased in communion. The narrated reactions were dominated by themes related to thwarted self-functioning and primarily identity, although intimacy was also present. Patients improved in terms of self-reported functioning and internalizing and externalizing behavior before and after end of treatment. The importance of narration in BPD (group) therapy is discussed alongside clinical implications. Full article
(This article belongs to the Special Issue ICD-11 Personality Disorder in Adolescents: Potentials and Pitfalls)
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14 pages, 268 KiB  
Article
Maladaptive Self- and Interpersonal Functioning Increments General Psychiatric Severity in the Association with Adolescent Personality Pathology
by Carla Sharp and Breana Rachelle Cervantes
Children 2023, 10(1), 120; https://doi.org/10.3390/children10010120 - 06 Jan 2023
Cited by 1 | Viewed by 1378
Abstract
Dimensionalized diagnostic systems, especially the entry criterion of maladaptive self and interpersonal functioning, hold particular advantages for the downward extension of personality pathology to young persons, but require conceptual clarification. The current study evaluated the distinctiveness of maladaptive self and interpersonal functioning by [...] Read more.
Dimensionalized diagnostic systems, especially the entry criterion of maladaptive self and interpersonal functioning, hold particular advantages for the downward extension of personality pathology to young persons, but require conceptual clarification. The current study evaluated the distinctiveness of maladaptive self and interpersonal functioning by examining its incremental value over and above general psychiatric severity in the association with personality pathology. A community sample of N = 419 youth (50.4% female; Mage = 11.91, SD = 1.19) between the ages of 10 and 14 completed measures of maladaptive self- and interpersonal functioning, general psychiatric severity (internalizing–externalizing spectrum), and personality pathology. Results showed that, as expected, maladaptive self- and interpersonal functioning incremented general psychiatric severity in the association with personality pathology in adolescents. Results contribute to the literature base illustrating the value of the entry criterion of the ICD-11 and AMPD diagnostic system. Full article
(This article belongs to the Special Issue ICD-11 Personality Disorder in Adolescents: Potentials and Pitfalls)
10 pages, 250 KiB  
Article
Adapting Short-Term Mentalization-Based Therapy to ICD-11 Personality Disorder in Adolescents
by Sebastian Simonsen, Emilie Hestbæk and Sophie Juul
Children 2023, 10(1), 93; https://doi.org/10.3390/children10010093 - 02 Jan 2023
Cited by 1 | Viewed by 1911
Abstract
Following the introduction of the 11th revision of the International Classification of Diseases (ICD-11), adolescents can now be diagnosed with a personality disorder based on severity ranging from mild to moderate to severe. This dimensional model has potential implications for treatment, as it [...] Read more.
Following the introduction of the 11th revision of the International Classification of Diseases (ICD-11), adolescents can now be diagnosed with a personality disorder based on severity ranging from mild to moderate to severe. This dimensional model has potential implications for treatment, as it allows clinicians and researchers to search for effective treatments targeting adolescents at different severity levels rather than offering all patients the same treatment. In this conceptual paper, we propose that the short-term mentalization-based therapy (MBT) program, originally developed to treat adults with borderline personality disorder (BPD), has potential clinical advantages for adolescents with ICD-11 personality disorder at the mild to moderate severity level. The short-term MBT program is a 5-month structured treatment approach including individual therapy, combined psychotherapy with the individual therapist also being one of the group therapists, and closed-group therapy to enhance cohesion and a feeling of security. The purpose of this paper is to make a case for the use of this format, as opposed to the traditional long-term MBT format, for adolescents with BPD. Future research should include large-scale randomized clinical trials powered to assess patient-important outcomes. Full article
(This article belongs to the Special Issue ICD-11 Personality Disorder in Adolescents: Potentials and Pitfalls)
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